Telehealth Consent

Alchemical Transformations Health Services, P.C.

Last updated: July 3, 2026

BY CLICKING “I AGREE,” CHECKING A BOX PRESENTED WITH THIS CONSENT, OR OTHERWISE AFFIRMATIVELY INDICATING ACCEPTANCE THROUGH THE PRACTICE’S WEBSITE OR INTAKE PROCESS, YOU AGREE TO THE TERMS OF THIS TELEMEDICINE INFORMED CONSENT. THE RISKS, BENEFITS, AND ALTERNATIVES TO TELEMEDICINE ARE DESCRIBED BELOW AND WERE MADE AVAILABLE TO YOU BEFORE ACCEPTANCE. IF YOU DO NOT AGREE, DO NOT SCHEDULE A CONSULTATION OR USE THE PRACTICE’S SERVICES.

IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM. IF YOU ARE IN A MENTAL HEALTH CRISIS OR CONTEMPLATING SUICIDE, CALL OR TEXT 988.

Alchemical Transformations Health Services, P.C. (the “Practice”) delivers medical care through telemedicine, meaning the delivery of health care services by a physician or other licensed health professional (a “Provider”) who is located at a different site than the patient, using electronic communications and information technology. By accepting this consent, I acknowledge the following:

1. 1. 1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit, that the Practice delivers care exclusively through telemedicine by Providers licensed in Texas, and that if my condition requires an in-person examination or treatment the Practice cannot provide, my Provider will direct me to appropriate in-person care.
      2. I understand that my care may be provided through live audio-video consultations or asynchronously, meaning a Provider reviews my intake responses, medical history, laboratory results, images, or messages and responds at a later time.
      3. I understand that there are risks to using technology in my care, including service interruptions, technical failures, and interception or breach of my information despite reasonable safeguards, and that evaluation without a hands-on physical examination has limits, including the possibility that my Provider cannot identify a condition or the need for urgent care. If the audio-video connection is not adequate, my Provider or I may discontinue the visit and make other arrangements to complete it.
      4. I understand that my Provider exercises independent medical judgment, that completing an intake questionnaire or paying for a consultation does not entitle me to a prescription or to any particular treatment, that no outcome is guaranteed, and that certain medications are subject to additional federal and state telemedicine requirements that may affect how they are prescribed.
      5. I understand that I will be notified of, and my consent obtained for, any person other than my Provider present during a visit, and that a documentation tool that transcribes the visit may be used with my consent to assist in preparing the clinical note; the note becomes part of my medical record.
      6. I understand that I may refuse to participate in or stop a telemedicine visit at any time, that my refusal will be documented in my medical record and will not affect my right to future care or treatment, and that I may revoke this consent at any time by written notice to the Practice at [PRACTICE EMAIL].
      7. I understand that the laws protecting the privacy and confidentiality of health care information, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Texas Health and Safety Code Chapter 181, apply to telemedicine services, and I acknowledge that the Practice’s Notice of Privacy Practices, available at [NPP URL], was made available to me before my first telemedicine evaluation.
      8. I understand that the Practice is a cash-pay practice that does not participate in or submit claims to commercial insurance, Medicare, Medicaid, or any other government health care program, and that fees for professional services are disclosed before scheduling and are due at that time. Laboratory testing and medications are separate charges payable to the laboratory or pharmacy that provides them. Payment terms are described at [PAYMENT TERMS URL].
      9. I attest that I am at least 18 years old, that the information I provide to the Practice is true, accurate, and complete, and that I am physically located in the State of Texas during each telemedicine visit and will confirm my location at the start of each visit.
      10. I understand that this consent becomes part of my medical record and that my electronic acceptance has the same force and effect as a handwritten signature.

This consent is effective upon acceptance and remains in effect for all telemedicine services I receive from the Practice until revoked.

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, surgical assistants, medical radiologic technologists, non-certified radiologic technicians, respiratory care practitioners, medical physicists, and perfusionists may be reported for investigation at the following address:

Texas Medical Board
Attention: Investigations
1801 Congress Avenue, Suite 9.200
P.O. Box 2018
Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number:

1-800-201-9353

For more information, please visit our website at

www.tmb.state.tx.us

AVISO SOBRE LAS QUEJAS

Quejas sobre médicos, así como sobre otros profesionales médicos de la Junta Médica de Texas, incluyendo asistentes médicos profesionales, acupunturistas, asistentes quirúrgicos, tecnólogos médicos en radiología, técnicos radiólogos no certificados, profesionales de cuidados respiratorios, físicos médicos, y perfusionistas se pueden presentar en la siguiente dirección para ser investigadas:

Texas Medical Board
Attention: Investigations
1801 Congress Avenue, Suite 9.200
P.O. Box 2018
Austin, Texas 78768-2018

Si necesita ayuda para presentar una queja, llame al:

1-800-201-9353

Para obtener más información, visite nuestro sitio web en

www.tmb.state.tx.us